In Japan and countries such as South Korea and Tai-wan, China, the standard technique for detecting earlygastric cancer (EGC) is chromoendoscopy. This technique involves a magnified endoscope and the use ofan indigo-c...In Japan and countries such as South Korea and Tai-wan, China, the standard technique for detecting earlygastric cancer (EGC) is chromoendoscopy. This technique involves a magnified endoscope and the use ofan indigo-carmine spray to distinguish between EGCand non-EGC areas. However, this technique is notwidely adopted in many parts of the world. One important reason for limited use is that this technique needsan experienced endoscopist to interpret the imagesduring the procedure. In addition, the sensitivity for detecting gastric intestinal metaplasia (GIM), a precancerous lesion of EGC, is graded as suboptimal. Moreover,the requirement of a cumbersome spraying method isinconvenient and needs preparation time. Easier digitalchromoendoscopy techniques, such as Narrow-bandImaging and Flexible spectral Imaging Color Enhancement, have been reported to facilitate targeted GIM and EGC biopsy. They provide higher sensitivities over conventional white light endoscopy. Recently, the noveltechnology of confocal laser endomicroscopy has been introduced as a high-magnification (1000 ×) real-time evaluation for many early gastrointestinal (GI) cancersand precancerous GI lesions, including colonic polyp,Barrett's esophagus, and GIM. The advantage of this technique is that it can be used as an in vivo confirmation of the presence of GIM and EGC during endoscopic surveillance. This review aims to explain the current information on the usefulness of digital chromoendos-copy and confocal laser endomicroscopy for evaluating GIM and EGC during endoscopic surveillance and the possible future role of these techniques for GI cancerscreening programs.展开更多
AIM: To provide consensus statements on the use of per-oral cholangiopancreatoscopy(POCPS).METHODS: A workgroup of experts in endoscopic retrograde cholangiopancreatography(ERCP), endosonography, and POCPS generated c...AIM: To provide consensus statements on the use of per-oral cholangiopancreatoscopy(POCPS).METHODS: A workgroup of experts in endoscopic retrograde cholangiopancreatography(ERCP), endosonography, and POCPS generated consensus statements summarizing the utility of POCPS in pancreaticobiliary disease. Recommendation grades used validated evidence ratings of publications from an extensive literature review.RESULTS: Six consensus statements were generated:(1) POCPS is now an important additional tool during ERCP;(2) in patients with indeterminate biliary strictures, POCS and POCS-guided targeted biopsy are useful for establishing a definitive diagnosis;(3) POCS and POCS-guided lithotripsy are recommended for treatment of difficult common bile duct stones when standard techniques fail;(4) in patients with main duct intraductal papillary mucinous neoplasms(IPMN) POPS may be used to assess extent of tumor to assist surgicalresection;(5) in difficult pancreatic ductal stones,POPS-guided lithotripsy may be useful in fragmentation and extraction of stones; and(6) additional indications for POCPS include selective guidewire placement,unexplained hemobilia, assessing intraductal biliary ablation therapy, and extracting migrated stents. CONCLUSION: POCPS is important in association with ERCP, particularly for diagnosis of indeterminate biliary strictures and for intra-ductal lithotripsy when other techniques failed, and may be useful for preoperative assessment of extent of main duct IPMN, for extraction of difficult pancreatic stones, and for unusua indications involving selective guidewire placement,assessing unexplained hemobilia or intraductal biliary ablation therapy, and extracting migrated stents.展开更多
AIM: To evaluate the efficacy of dipstick test in diagnosis of spontaneous bacterial peritonitis (SBP) in cirrhotic patients who underwent abdominal paracentesis based on the locally available dipstick test. METHODS: ...AIM: To evaluate the efficacy of dipstick test in diagnosis of spontaneous bacterial peritonitis (SBP) in cirrhotic patients who underwent abdominal paracentesis based on the locally available dipstick test. METHODS: There were 200 consecutive samples from cirrhotic patients who underwent abdominal paracentesis. Urine dipstick (Combur10 Test?M, Roche, Mannheim, Germany) was used as a screening test. A manual cell count with differential study was done in all samples by experienced technicians. The polymorphonuclear (PMN) cell count more than 250 cells/mm3 was used as a diagnostic cut off level. One to three plus dipstick results were used as cut off levels for a positive result. The dipstick test results had to be agreed by three experienced readers. The sensitivity, specificity, positive and negative predictive values and accuracy of two different colorimetric cut off scales (1+ and 2+) were calculated and compared. RESULTS: The prevalence of SBP diagnosed by manual cell count was 21.0%. There were 128 specimens that had a true negative result by dipstick. The sensitivity, specificity, positive and negative predictive values and accuracy of 1+ and 2+ cut off scale to diagnose SBP were 88%, 81%, 55%, 96% and 83% respectively, and 63%, 96%, 82%, 81% and 89% respectively. CONCLUSION: Dipstick test can be used as a rapid test for screening of SBP. The higher cut off colorimetric scale has a better specificity and positive predictive value but a lower sensitivity.展开更多
In patients with a malignant biliary obstruction who require biliary drainage,a self-expandable metallic stent(SEMS) provides longer patency duration than a plastic stent(PS).Nevertheless,a stent occlusion by tumor in...In patients with a malignant biliary obstruction who require biliary drainage,a self-expandable metallic stent(SEMS) provides longer patency duration than a plastic stent(PS).Nevertheless,a stent occlusion by tumor ingrowth,tumor overgrowth and biliary sludge may develop.There are several methods to manage occluded SEMS.Endoscopic management is the preferred treatment,whereas percutaneous intervention is an alternative approach.Endoscopic treatment involves mechanical cleaning with a balloon and a second stent insertion as stent-in-stent with either PS or SEMS.Technical feasibility,patient survival and cost-effectiveness are important factors that determine the method of re-drainage and stent selection.展开更多
AIM： To evaluate the efficacy of non-sequential narrow band imaging （NBI） for a better recognition of gastric intestinal metaplasia （GIM）. METHODS： Previously diagnosed GIM patients underwent targeted biopsy fro...AIM： To evaluate the efficacy of non-sequential narrow band imaging （NBI） for a better recognition of gastric intestinal metaplasia （GIM）. METHODS： Previously diagnosed GIM patients underwent targeted biopsy from areas with and without GIM, as indicated by NBI, twice at an interval of 1 year. The authors compared the endoscopic criteria such as light blue crest （LBC）, villous pattern （VP）, and large long crest （LLC） with standard histology. The results from two surveillance endoscopies were compared with histology results for sensitivity, specificity, positive predic-tive value （PPV）, negative predictive value （NPV）, and likelihood ratio of positive test （LR＋）. The number of early gastric cancer cases detected was also reported. RESULTS： NBI targeted biopsy was performed in 38 and 26 patients during the first and second surveillance endoscopies, respectively. There were 2 early gastric cancers detected in the first endoscopy. No cancer was detected from the second study. Surgical and endoscopic resections were successfully performed in each patient. Sensitivity, specificity, PPV, NPV, and LR＋ of all 3 endoscopic criteria during the first/second surveillances were 78.8%/91.3%, 82.5%/89.1%, 72.8%/77.8%, 86.8%/96.1, and 4.51/8.4, respectively. LBC provided the highest LR＋ over VP and LLC. CONCLUSION： Nonequential NBI is useful for GIM targeted biopsy. LBC provides the most sensitive reading. However, the optimal duration between two surveillances requires further study.展开更多
AIM： To evaluate the efficacy and safety of gastric varices injection with cyanoacrylate in patients with gastric variceal bleeding. METHODS： Twenty-four patients （15 males, 9 females） with gastric variceal bleedi...AIM： To evaluate the efficacy and safety of gastric varices injection with cyanoacrylate in patients with gastric variceal bleeding. METHODS： Twenty-four patients （15 males, 9 females） with gastric variceal bleeding underwent endoscopic treatment with cyanoacrylate injection. Successful hemostasis, rebleeding rate, and complications were retrospectively reviewed. Followed up endoscopy was performed and repeat cyanoacrylate injection was given until gastric varices were obliterated. RESULTS： Seventeen patients achieved definite hemostasis. Of these, 14 patients had primary success after initial endoscopic therapy. Ten patients developed recurrent bleeding. Repeated cyanoacrylate injection stopped rebleeding in three patients. Transjugular intrahepatic portosystemic shunt （TIPS） was performed to control rebleeding in one patient which occured after repeat endoscopic therapy. Six patients died （three from uncontrolled bleeding, two from sepsis, and one from mesenteric vein thrombosis）. Minor complications occurred in 11 patients （six epigastric discomfort and five post injection ulcers）. Cyanoacrylate embolism developed in two patients. One of these patients died from mesenteric vein thrombosis. The other had pulmonary embolism which resolved spontaneously. Advanced drrhosis and hepatocellular carcinoma （HCC） were major risk factors for uncontrolled bleeding. CONCLUSION： Endoscopic treatment for bleeding gastric varices with cyanoacrylate injection is effective for immediate hemostasis. Repeat cyanoacrylate injection has a lower success rate than the initial injection. Cyanoacrylate embolism is not a common serious complication.展开更多
AIM To compare high definition white light endoscopy and bright narrow band imaging for colon polyps' detection rates. METHODS Patients were randomised to high definition white light endoscopy(HD-WLE) or the brigh...AIM To compare high definition white light endoscopy and bright narrow band imaging for colon polyps' detection rates. METHODS Patients were randomised to high definition white light endoscopy(HD-WLE) or the bright narrow band imaging(b NBI) during withdrawal of the colonoscope. Polyps identified in either mode were characterised using b NBI with dual focus(b NBI-DF) according to the Sano's classification. The primary outcome was to compare adenoma detection rates(ADRs) between the two arms. The secondary outcome was to assess the negative predictive value(NPV) in differentiating adenomas from hyperplastic polyps for diminutive rectosigmoid lesions.RESULTS A total of 1006 patients were randomised to HD-WLE(n = 511) or b NBI(n = 495). The mean of adenoma per patient was 1.62 and 1.84, respectively. The ADRs in b NBI and HD-WLE group were 37.4% and 39.3%, respectively. When adjusted for withdrawal time(OR = 1.19, 95%CI: 1.15-1.24, P < 0.001), the use of b NBI was associated with a reduced ADR(OR = 0.69, 95%CI: 0.52-0.92). Nine hundred and thirty three polyps(86%) in both arms were predicted with high confidence. The sensitivity(Sn), specificity(Sp), positive predictive value and NPV in differentiating adenomatous from non-adenomatous polyps of all sizes were 95.9%, 87.2%, 94.0% and 91.1% respectively. The NPV in differentiating an adenoma from hyperplastic polyp using b NBI-DF for diminutive rectal polyps was 91.0%.CONCLUSION ADRs did not differ between b NBI and HD-WLE, however HD-WLE had higher ADR after adjustment of withdrawal time. b NBI surpassed the PIVI threshold for diminutive polyps.展开更多
Endoscopy is a widely used diagnostic tool to detect reflux esophagitis.Although its specificity was reported to be excellent at 90%-95%,its sensitivity was only 50%.Therefore,it is quite difficult to detect these les...Endoscopy is a widely used diagnostic tool to detect reflux esophagitis.Although its specificity was reported to be excellent at 90%-95%,its sensitivity was only 50%.Therefore,it is quite difficult to detect these lesions under the standard white light endoscopy especially in patients with minimal change esophageal reflux disease(MERD).In recent years,endoscopic technologies have evolved tremendously;these include high resolution and magnification digital chromoendoscopy.These technologies are useful practically for detecting various subtle lesions along the gastrointestinal tract starting from esophagus to colon.Currently,these technologies can be classified in 2 systems;pre-processed system(NBI,Olympus)and post processed system(FICE and i-SCAN,Fujinon and Pentax respectively).Over a few years,there have been many emerging publications on the benefit of these systems on MERD detection.The overall sensitivities to diagnose MERD were reported as much better than controls.However,large,multi-center and randomized controlled studies comparing these new imaging modalities with the conventional white light chromoendoscopy are warranted to validate its accuracy.Standard,simple and precise endoscopic reading criteria for the identification of MERD are also required.展开更多
To report the result of rapid ulcer healing by infliximab in Crohn's patients with severe enterocolic bleeding. During 2005 and 2010, inflammatory bowel disease database of King Chulalongkorn Memorial and Samitive...To report the result of rapid ulcer healing by infliximab in Crohn's patients with severe enterocolic bleeding. During 2005 and 2010, inflammatory bowel disease database of King Chulalongkorn Memorial and Samitivej hospitals were reviewed. There were seven Crohn's disease (CD) patients (4 women and 3 men; mean age 52 ± 10.4 years; range: 11-86 years). Two of the seven patients developed severe gastrointestinal bleeding (GIB) as a flare up of CD whereas the other five patients presented with GIB as their first symptom for CD. Their mean hemoglobin level dropped from 12 ± 1.3 g/ dL to 8.7 ± 1.3 g/dL in a 3-d period. Median packed red blood cells units needed for resuscitation was 4 units. Because of uncontrolled bleeding, surgical resection was considered. However, due to the poor surgical candidacy of these patients (n = 3) and /or possible development of short bowel syndrome (n = 6), surgery was not pursued. Likewise angiographic embolization was not considered in any due to the risk of large infarction. All severe GIBs successfully stopped by one or two doses of intravenous infliximab. Our data suggests that infliximab is an alternative therapy for CD with severe GIB when surgery has limitation or patient is a high risk.展开更多
AIM: To analyze the differences of clinical characteristics of colorectal neoplasm including polyps between the elderly and young Thai patients.METHODS: Colonoscopy database from December 2000 to October 2004 was retr...AIM: To analyze the differences of clinical characteristics of colorectal neoplasm including polyps between the elderly and young Thai patients.METHODS: Colonoscopy database from December 2000 to October 2004 was retrospectively analyzed. There were 1822 eligible patients who underwent colonoscopy (with a mean age of 56.6 years). Patients were classified into two groups: the older age group (aged ≥ 60 years; n = 989) and the younger age group (aged < 60 years; n = 833). Data were recorded on age, colonoscopic indications, tumor location, colonoscopic findings and their related histological findings. RESULTS: Colorectal malignancy related lesions were more often found in the older age group (21%) than in the younger age group (12%). Left-sided lesions were detected more commonly than right-sided in both age groups in approximately two-thirds of all cases. Hematochezia showed greater association with left-sided lesions in the elderly. No relationship was found between age and neoplasm staging and severity.CONCLUSION: The chance of detecting colorectal neoplasm by colonoscopy was higher in the elderly than in the young Thais. However, both groups had the lesions predominantly located in the left side.展开更多
Traditionally,pre-operative biliary drainage(PBD) was believed to improve multi-organ dysfunction,and for this reason,was practiced worldwide.Over the last decade,this concept was challenged by many reports,including ...Traditionally,pre-operative biliary drainage(PBD) was believed to improve multi-organ dysfunction,and for this reason,was practiced worldwide.Over the last decade,this concept was challenged by many reports,including meta-analyses that showed no difference in morbidity and mortality between surgery with,and surgery without PBD,in operable malignant jaundice.The main disadvantages of PBD are seen to be the additional cost of the procedure itself,and the need for longer hospitalization.In addition,many studies showed the significance of specific complications resulting from PBD,such as recurrent jaundice,cholangitis,pancreatitis,cutaneous fistula,and bleeding.However,the results of these studies remain inconclusive as to date there has been no perfect study that equally randomized comparable patients according to the level of obstruction and technique used for PBD.Generally,endoscopic stent insertion(ES) is preferred for common duct obstruction,whereas endoscopic nasobiliary drainage and percutaneous biliary drainage is reserved for hilar obstruction,since ES in hilar block confers a high rate of cholangitis.Although,there is no guideline which either supports or refutes this approach,certain subgroups of patients,including those with symptomatic jaundice,cholangitis,impending renal failure,hilar block requiring preoperative portal vein embolization,and those who need pre-operative neoadjuvant therapy,are suitable candidates for PBD.展开更多
AIM： To compare the efficacy of enzymatic detergent with chlorhexidine for gastroscope bacterial decontamination. METHODS： A prospective randomized controlled study was undertaken to evaluate the ability of these 2 ...AIM： To compare the efficacy of enzymatic detergent with chlorhexidine for gastroscope bacterial decontamination. METHODS： A prospective randomized controlled study was undertaken to evaluate the ability of these 2 agents to achieve high level disinfection in a gastroscope. A total of 260 samples were collected from 5 different gastroscopes. Manual cleaning was done for 10 min with these 2 agents separately （n = 130 each）. Then all specimens underwent 2% glutaraldehyde soaking for 20 min. After 70% alcohol was rinsed, sterile normal saline was flushed into each gastroscope channel and 40 mL of sample was collected. The sample was sent for aerobic bacterial culture after membrane was filtered. A colony count greater than 200 cfu/mL was considered significant. RESULTS： The positive culture rate was 4.6% in the enzymatic detergent arm and 3.1% in the chlorhexidine arm. Pseudomonas species were the main organism detected from both groups （60%）. Multiple organisms were found from 4 specimens （enzymatic detergent arm = 1, chlorhexidine arm = 3）. CONCLUSION： The contamination rate of both types of cleaning solution is equivalent.展开更多
The covered self-expandable metallic stent(SEMS) has been developed to overcome the problem of tissue ingrowth,However,stent migration is a well-known complication of covered SEMS placement.Use of a double pigtail ste...The covered self-expandable metallic stent(SEMS) has been developed to overcome the problem of tissue ingrowth,However,stent migration is a well-known complication of covered SEMS placement.Use of a double pigtail stent to lock the movement of the SEMS and prevent migration has been advised by many experts.Unfortunately,in our case this technique led to an incidental upward migration of the SEMS.We used APC to create a side hole in the SEMS for plastic stent insertion as stent-in-stent.This led to a successful prevention of stent migration.展开更多
The aberrant hepatic duct is classified by Huang et al.[1]into type A(right intrahepatic duct variant)and type B(left intrahepatic duct variant).Type A and B are further classified into 5(A1-5)and 6(B1-6)subtypes,resp...The aberrant hepatic duct is classified by Huang et al.[1]into type A(right intrahepatic duct variant)and type B(left intrahepatic duct variant).Type A and B are further classified into 5(A1-5)and 6(B1-6)subtypes,respectively.The variation of cystic duct involves only in type A.Type A1 or classic arrangement refers to the formation of the common hepatic duct(CHD)by the left hepatic duct(LHD)and the right hepatic duct(RHD).The RHD has two tributaries composed of the right anterior hepatic duct(RAHD)and the right posterior hepatic duct(RPHD).Then,the common bile duct(CBD)is formed when the cystic duct joins with the CHD(Fig.1).Type A2 refers to the RAHD and RPHD joining with LHD at hepatic hilum,and the absence of the RHD.Type A3 refers to the RAHD or RPHD directly draining to the LHD.Type A4 refers to the RAHD or RPHD directly draining to the CHD.Type A5 refers to the RAHD,RPHD or RHD directly draining to the cystic duct(or aberrant bile duct communicating with the cystic duct,ACC)(Fig.1)[1].展开更多
BACKGROUND Volatile organic compounds(VOCs)are a promising potential biomarker that may be able to identify the presence of cancers.AIM To identify exhaled breath VOCs that distinguish pancreatic ductal adenocar-cinom...BACKGROUND Volatile organic compounds(VOCs)are a promising potential biomarker that may be able to identify the presence of cancers.AIM To identify exhaled breath VOCs that distinguish pancreatic ductal adenocar-cinoma(PDAC)from intraductal papillary mucinous neoplasm(IPMN)and healthy volunteers.METHODS We collected exhaled breath from histologically proven PDAC patients,radiological diagnosis IPMN,and healthy volunteers using the ReCIVA®device between 10/2021-11/2022.VOCs were identified by thermal desorption-gas chromatography/field-asymmetric ion mobility spectrometry and compared between groups.RESULTS A total of 156 participants(44%male,mean age 62.6±10.6)were enrolled(54 PDAC,42 IPMN,and 60 controls).Among the nine VOCs identified,two VOCs that showed differences between groups were dimethyl sulfide[0.73 vs 0.74 vs 0.94 arbitrary units(AU),respectively;P=0.008]and acetone dimers(3.95 vs 4.49 vs 5.19 AU,respectively;P<0.001).After adjusting for the imbalance parameters,PDAC showed higher dimethyl sulfide levels than the control and IPMN groups,with adjusted odds ratio(aOR)of 6.98(95%CI:1.15-42.17)and 4.56(1.03-20.20),respectively(P<0.05 both).Acetone dimer levels were also higher in PDAC compared to controls and IPMN(aOR:5.12(1.80-14.57)and aOR:3.35(1.47-7.63),respectively(P<0.05 both).Acetone dimer,but not dimethyl sulfide,performed better than CA19-9 in PDAC diagnosis(AUROC 0.910 vs 0.796).The AUROC of acetone dimer increased to 0.936 when combined with CA19-9,which was better than CA19-9 alone(P<0.05).CONCLUSION Dimethyl sulfide and acetone dimer are VOCs that potentially distinguish PDAC from IPMN and healthy participants.Additional prospective studies are required to validate these findings.展开更多
Objectives:The difficulties in the early detection consequent to the lack of sensitive biomarkers render patients with cholangiocarcinoma(CCA)to have poor outcomes.Recently,sensitive and specific volatile organic comp...Objectives:The difficulties in the early detection consequent to the lack of sensitive biomarkers render patients with cholangiocarcinoma(CCA)to have poor outcomes.Recently,sensitive and specific volatile organic compounds(VOCs)were identified in several cancers.However,the VOC profiles in CCA are not well-studied.Thus,we investigated the VOC profiles in exhaled breath of CCA patients and controls.Methods:We prospectively collected exhaled breath samples from 30 consecutive patients newly diagnosed with CCA and 30 controls who did not have CCA(seven had benign biliary strictures and 23 had other medical conditions).Exhaled VOCs were identified using gas chromatography mass spectrometry Triple Quadrupoles system.Analysis of the significant differences in VOCs between cases and controls was conducted using supervised multivariate regression analysis.Further validation was performed for these VOCs in another cohort of 18 CCA patients and 22 controls.Results:Levels of six compounds were significantly different between CCA patients and controls,namely,acetone,isopropyl alcohol,dimethyl sulfide,1,4-pentadiene,allyl methyl sulfide,and N,N-dimethylacetamide.Acetone and dimethyl sulfide were independently associated with CCA as demonstrated in the multivariate analysis.Using the cut-off value of 8.59107 arbitrary unit(AU),acetone had a sensitivity and specificity of 82.1%and 75.8%,respectively,with an area under the receiving operator curve(AUROC)of 0.85 for the CCA diagnosis.Acetone level was also significantly different between cases and controls in the validation cohort.Using the same cut-off value,the sensitivity,specificity,and AUROC was 59.1%,66.7%,and 0.85,respectively.Conclusion:Breath analysis may potentially be useful for CCA diagnosis.A cohort of patients with earlystage CCA in further studies is needed to confirm the ability of exhaled VOCs for the early detection of CCA.展开更多
Fibrosis resulting from pathological repair secondary to recurrent or persistent tissue damage often leads to organ failure and mortality.Biliary fibrosis is a crucial but easily neglected pathological feature in hepa...Fibrosis resulting from pathological repair secondary to recurrent or persistent tissue damage often leads to organ failure and mortality.Biliary fibrosis is a crucial but easily neglected pathological feature in hepatobiliary disorders,which may promote the development and progression of benign and malignant biliary diseases through pathological healing mechanisms secondary to biliary tract injuries.Elucidating the etiology and pathogenesis of biliary fibrosis is beneficial to the prevention and treatment of biliary diseases.In this review,we emphasized the importance of biliary fibrosis in cholangiopathies and summarized the clinical manifestations,epidemiology,and aberrant cellular composition involving the biliary ductules,cholangiocytes,immune system,fibroblasts,and the microbiome.We also focused on pivotal signaling pathways and offered insights into ongoing clinical trials and proposing a strategic approach for managing biliary fibrosis-related cholangiopathies.This review will offer a comprehensive perspective on biliary fibrosis and provide an important reference for future mechanism research and innovative therapy to prevent or reverse fibrosis.展开更多
文摘In Japan and countries such as South Korea and Tai-wan, China, the standard technique for detecting earlygastric cancer (EGC) is chromoendoscopy. This technique involves a magnified endoscope and the use ofan indigo-carmine spray to distinguish between EGCand non-EGC areas. However, this technique is notwidely adopted in many parts of the world. One important reason for limited use is that this technique needsan experienced endoscopist to interpret the imagesduring the procedure. In addition, the sensitivity for detecting gastric intestinal metaplasia (GIM), a precancerous lesion of EGC, is graded as suboptimal. Moreover,the requirement of a cumbersome spraying method isinconvenient and needs preparation time. Easier digitalchromoendoscopy techniques, such as Narrow-bandImaging and Flexible spectral Imaging Color Enhancement, have been reported to facilitate targeted GIM and EGC biopsy. They provide higher sensitivities over conventional white light endoscopy. Recently, the noveltechnology of confocal laser endomicroscopy has been introduced as a high-magnification (1000 ×) real-time evaluation for many early gastrointestinal (GI) cancersand precancerous GI lesions, including colonic polyp,Barrett's esophagus, and GIM. The advantage of this technique is that it can be used as an in vivo confirmation of the presence of GIM and EGC during endoscopic surveillance. This review aims to explain the current information on the usefulness of digital chromoendos-copy and confocal laser endomicroscopy for evaluating GIM and EGC during endoscopic surveillance and the possible future role of these techniques for GI cancerscreening programs.
文摘AIM: To provide consensus statements on the use of per-oral cholangiopancreatoscopy(POCPS).METHODS: A workgroup of experts in endoscopic retrograde cholangiopancreatography(ERCP), endosonography, and POCPS generated consensus statements summarizing the utility of POCPS in pancreaticobiliary disease. Recommendation grades used validated evidence ratings of publications from an extensive literature review.RESULTS: Six consensus statements were generated:(1) POCPS is now an important additional tool during ERCP;(2) in patients with indeterminate biliary strictures, POCS and POCS-guided targeted biopsy are useful for establishing a definitive diagnosis;(3) POCS and POCS-guided lithotripsy are recommended for treatment of difficult common bile duct stones when standard techniques fail;(4) in patients with main duct intraductal papillary mucinous neoplasms(IPMN) POPS may be used to assess extent of tumor to assist surgicalresection;(5) in difficult pancreatic ductal stones,POPS-guided lithotripsy may be useful in fragmentation and extraction of stones; and(6) additional indications for POCPS include selective guidewire placement,unexplained hemobilia, assessing intraductal biliary ablation therapy, and extracting migrated stents. CONCLUSION: POCPS is important in association with ERCP, particularly for diagnosis of indeterminate biliary strictures and for intra-ductal lithotripsy when other techniques failed, and may be useful for preoperative assessment of extent of main duct IPMN, for extraction of difficult pancreatic stones, and for unusua indications involving selective guidewire placement,assessing unexplained hemobilia or intraductal biliary ablation therapy, and extracting migrated stents.
文摘AIM: To evaluate the efficacy of dipstick test in diagnosis of spontaneous bacterial peritonitis (SBP) in cirrhotic patients who underwent abdominal paracentesis based on the locally available dipstick test. METHODS: There were 200 consecutive samples from cirrhotic patients who underwent abdominal paracentesis. Urine dipstick (Combur10 Test?M, Roche, Mannheim, Germany) was used as a screening test. A manual cell count with differential study was done in all samples by experienced technicians. The polymorphonuclear (PMN) cell count more than 250 cells/mm3 was used as a diagnostic cut off level. One to three plus dipstick results were used as cut off levels for a positive result. The dipstick test results had to be agreed by three experienced readers. The sensitivity, specificity, positive and negative predictive values and accuracy of two different colorimetric cut off scales (1+ and 2+) were calculated and compared. RESULTS: The prevalence of SBP diagnosed by manual cell count was 21.0%. There were 128 specimens that had a true negative result by dipstick. The sensitivity, specificity, positive and negative predictive values and accuracy of 1+ and 2+ cut off scale to diagnose SBP were 88%, 81%, 55%, 96% and 83% respectively, and 63%, 96%, 82%, 81% and 89% respectively. CONCLUSION: Dipstick test can be used as a rapid test for screening of SBP. The higher cut off colorimetric scale has a better specificity and positive predictive value but a lower sensitivity.
文摘In patients with a malignant biliary obstruction who require biliary drainage,a self-expandable metallic stent(SEMS) provides longer patency duration than a plastic stent(PS).Nevertheless,a stent occlusion by tumor ingrowth,tumor overgrowth and biliary sludge may develop.There are several methods to manage occluded SEMS.Endoscopic management is the preferred treatment,whereas percutaneous intervention is an alternative approach.Endoscopic treatment involves mechanical cleaning with a balloon and a second stent insertion as stent-in-stent with either PS or SEMS.Technical feasibility,patient survival and cost-effectiveness are important factors that determine the method of re-drainage and stent selection.
基金Supported by The Gastroenterological Association of Thailand: grant for Gastroenterology Fellow 2007
文摘AIM： To evaluate the efficacy of non-sequential narrow band imaging （NBI） for a better recognition of gastric intestinal metaplasia （GIM）. METHODS： Previously diagnosed GIM patients underwent targeted biopsy from areas with and without GIM, as indicated by NBI, twice at an interval of 1 year. The authors compared the endoscopic criteria such as light blue crest （LBC）, villous pattern （VP）, and large long crest （LLC） with standard histology. The results from two surveillance endoscopies were compared with histology results for sensitivity, specificity, positive predic-tive value （PPV）, negative predictive value （NPV）, and likelihood ratio of positive test （LR＋）. The number of early gastric cancer cases detected was also reported. RESULTS： NBI targeted biopsy was performed in 38 and 26 patients during the first and second surveillance endoscopies, respectively. There were 2 early gastric cancers detected in the first endoscopy. No cancer was detected from the second study. Surgical and endoscopic resections were successfully performed in each patient. Sensitivity, specificity, PPV, NPV, and LR＋ of all 3 endoscopic criteria during the first/second surveillances were 78.8%/91.3%, 82.5%/89.1%, 72.8%/77.8%, 86.8%/96.1, and 4.51/8.4, respectively. LBC provided the highest LR＋ over VP and LLC. CONCLUSION： Nonequential NBI is useful for GIM targeted biopsy. LBC provides the most sensitive reading. However, the optimal duration between two surveillances requires further study.
文摘AIM： To evaluate the efficacy and safety of gastric varices injection with cyanoacrylate in patients with gastric variceal bleeding. METHODS： Twenty-four patients （15 males, 9 females） with gastric variceal bleeding underwent endoscopic treatment with cyanoacrylate injection. Successful hemostasis, rebleeding rate, and complications were retrospectively reviewed. Followed up endoscopy was performed and repeat cyanoacrylate injection was given until gastric varices were obliterated. RESULTS： Seventeen patients achieved definite hemostasis. Of these, 14 patients had primary success after initial endoscopic therapy. Ten patients developed recurrent bleeding. Repeated cyanoacrylate injection stopped rebleeding in three patients. Transjugular intrahepatic portosystemic shunt （TIPS） was performed to control rebleeding in one patient which occured after repeat endoscopic therapy. Six patients died （three from uncontrolled bleeding, two from sepsis, and one from mesenteric vein thrombosis）. Minor complications occurred in 11 patients （six epigastric discomfort and five post injection ulcers）. Cyanoacrylate embolism developed in two patients. One of these patients died from mesenteric vein thrombosis. The other had pulmonary embolism which resolved spontaneously. Advanced drrhosis and hepatocellular carcinoma （HCC） were major risk factors for uncontrolled bleeding. CONCLUSION： Endoscopic treatment for bleeding gastric varices with cyanoacrylate injection is effective for immediate hemostasis. Repeat cyanoacrylate injection has a lower success rate than the initial injection. Cyanoacrylate embolism is not a common serious complication.
文摘AIM To compare high definition white light endoscopy and bright narrow band imaging for colon polyps' detection rates. METHODS Patients were randomised to high definition white light endoscopy(HD-WLE) or the bright narrow band imaging(b NBI) during withdrawal of the colonoscope. Polyps identified in either mode were characterised using b NBI with dual focus(b NBI-DF) according to the Sano's classification. The primary outcome was to compare adenoma detection rates(ADRs) between the two arms. The secondary outcome was to assess the negative predictive value(NPV) in differentiating adenomas from hyperplastic polyps for diminutive rectosigmoid lesions.RESULTS A total of 1006 patients were randomised to HD-WLE(n = 511) or b NBI(n = 495). The mean of adenoma per patient was 1.62 and 1.84, respectively. The ADRs in b NBI and HD-WLE group were 37.4% and 39.3%, respectively. When adjusted for withdrawal time(OR = 1.19, 95%CI: 1.15-1.24, P < 0.001), the use of b NBI was associated with a reduced ADR(OR = 0.69, 95%CI: 0.52-0.92). Nine hundred and thirty three polyps(86%) in both arms were predicted with high confidence. The sensitivity(Sn), specificity(Sp), positive predictive value and NPV in differentiating adenomatous from non-adenomatous polyps of all sizes were 95.9%, 87.2%, 94.0% and 91.1% respectively. The NPV in differentiating an adenoma from hyperplastic polyp using b NBI-DF for diminutive rectal polyps was 91.0%.CONCLUSION ADRs did not differ between b NBI and HD-WLE, however HD-WLE had higher ADR after adjustment of withdrawal time. b NBI surpassed the PIVI threshold for diminutive polyps.
文摘Endoscopy is a widely used diagnostic tool to detect reflux esophagitis.Although its specificity was reported to be excellent at 90%-95%,its sensitivity was only 50%.Therefore,it is quite difficult to detect these lesions under the standard white light endoscopy especially in patients with minimal change esophageal reflux disease(MERD).In recent years,endoscopic technologies have evolved tremendously;these include high resolution and magnification digital chromoendoscopy.These technologies are useful practically for detecting various subtle lesions along the gastrointestinal tract starting from esophagus to colon.Currently,these technologies can be classified in 2 systems;pre-processed system(NBI,Olympus)and post processed system(FICE and i-SCAN,Fujinon and Pentax respectively).Over a few years,there have been many emerging publications on the benefit of these systems on MERD detection.The overall sensitivities to diagnose MERD were reported as much better than controls.However,large,multi-center and randomized controlled studies comparing these new imaging modalities with the conventional white light chromoendoscopy are warranted to validate its accuracy.Standard,simple and precise endoscopic reading criteria for the identification of MERD are also required.
文摘To report the result of rapid ulcer healing by infliximab in Crohn's patients with severe enterocolic bleeding. During 2005 and 2010, inflammatory bowel disease database of King Chulalongkorn Memorial and Samitivej hospitals were reviewed. There were seven Crohn's disease (CD) patients (4 women and 3 men; mean age 52 ± 10.4 years; range: 11-86 years). Two of the seven patients developed severe gastrointestinal bleeding (GIB) as a flare up of CD whereas the other five patients presented with GIB as their first symptom for CD. Their mean hemoglobin level dropped from 12 ± 1.3 g/ dL to 8.7 ± 1.3 g/dL in a 3-d period. Median packed red blood cells units needed for resuscitation was 4 units. Because of uncontrolled bleeding, surgical resection was considered. However, due to the poor surgical candidacy of these patients (n = 3) and /or possible development of short bowel syndrome (n = 6), surgery was not pursued. Likewise angiographic embolization was not considered in any due to the risk of large infarction. All severe GIBs successfully stopped by one or two doses of intravenous infliximab. Our data suggests that infliximab is an alternative therapy for CD with severe GIB when surgery has limitation or patient is a high risk.
基金Supported by 90th Anniversary Fund of Chulalongkorn University(Ratchada phiseksomphot Endowment Fund)The Grant of Ratchadaphiseksomphot,Faculty of Medicine,Chulalongkorn University,Bangkok,Thailand
文摘AIM: To evaluate the protective effects of Aloe vera on gastric injury in rats with indomethacin (IMN)-induced gastropathy.
文摘AIM: To analyze the differences of clinical characteristics of colorectal neoplasm including polyps between the elderly and young Thai patients.METHODS: Colonoscopy database from December 2000 to October 2004 was retrospectively analyzed. There were 1822 eligible patients who underwent colonoscopy (with a mean age of 56.6 years). Patients were classified into two groups: the older age group (aged ≥ 60 years; n = 989) and the younger age group (aged < 60 years; n = 833). Data were recorded on age, colonoscopic indications, tumor location, colonoscopic findings and their related histological findings. RESULTS: Colorectal malignancy related lesions were more often found in the older age group (21%) than in the younger age group (12%). Left-sided lesions were detected more commonly than right-sided in both age groups in approximately two-thirds of all cases. Hematochezia showed greater association with left-sided lesions in the elderly. No relationship was found between age and neoplasm staging and severity.CONCLUSION: The chance of detecting colorectal neoplasm by colonoscopy was higher in the elderly than in the young Thais. However, both groups had the lesions predominantly located in the left side.
文摘Traditionally,pre-operative biliary drainage(PBD) was believed to improve multi-organ dysfunction,and for this reason,was practiced worldwide.Over the last decade,this concept was challenged by many reports,including meta-analyses that showed no difference in morbidity and mortality between surgery with,and surgery without PBD,in operable malignant jaundice.The main disadvantages of PBD are seen to be the additional cost of the procedure itself,and the need for longer hospitalization.In addition,many studies showed the significance of specific complications resulting from PBD,such as recurrent jaundice,cholangitis,pancreatitis,cutaneous fistula,and bleeding.However,the results of these studies remain inconclusive as to date there has been no perfect study that equally randomized comparable patients according to the level of obstruction and technique used for PBD.Generally,endoscopic stent insertion(ES) is preferred for common duct obstruction,whereas endoscopic nasobiliary drainage and percutaneous biliary drainage is reserved for hilar obstruction,since ES in hilar block confers a high rate of cholangitis.Although,there is no guideline which either supports or refutes this approach,certain subgroups of patients,including those with symptomatic jaundice,cholangitis,impending renal failure,hilar block requiring preoperative portal vein embolization,and those who need pre-operative neoadjuvant therapy,are suitable candidates for PBD.
文摘AIM： To compare the efficacy of enzymatic detergent with chlorhexidine for gastroscope bacterial decontamination. METHODS： A prospective randomized controlled study was undertaken to evaluate the ability of these 2 agents to achieve high level disinfection in a gastroscope. A total of 260 samples were collected from 5 different gastroscopes. Manual cleaning was done for 10 min with these 2 agents separately （n = 130 each）. Then all specimens underwent 2% glutaraldehyde soaking for 20 min. After 70% alcohol was rinsed, sterile normal saline was flushed into each gastroscope channel and 40 mL of sample was collected. The sample was sent for aerobic bacterial culture after membrane was filtered. A colony count greater than 200 cfu/mL was considered significant. RESULTS： The positive culture rate was 4.6% in the enzymatic detergent arm and 3.1% in the chlorhexidine arm. Pseudomonas species were the main organism detected from both groups （60%）. Multiple organisms were found from 4 specimens （enzymatic detergent arm = 1, chlorhexidine arm = 3）. CONCLUSION： The contamination rate of both types of cleaning solution is equivalent.
文摘The covered self-expandable metallic stent(SEMS) has been developed to overcome the problem of tissue ingrowth,However,stent migration is a well-known complication of covered SEMS placement.Use of a double pigtail stent to lock the movement of the SEMS and prevent migration has been advised by many experts.Unfortunately,in our case this technique led to an incidental upward migration of the SEMS.We used APC to create a side hole in the SEMS for plastic stent insertion as stent-in-stent.This led to a successful prevention of stent migration.
基金funded by National Research Council of Thailand (NRCT:N42A640330)supported by Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology
文摘The aberrant hepatic duct is classified by Huang et al.[1]into type A(right intrahepatic duct variant)and type B(left intrahepatic duct variant).Type A and B are further classified into 5(A1-5)and 6(B1-6)subtypes,respectively.The variation of cystic duct involves only in type A.Type A1 or classic arrangement refers to the formation of the common hepatic duct(CHD)by the left hepatic duct(LHD)and the right hepatic duct(RHD).The RHD has two tributaries composed of the right anterior hepatic duct(RAHD)and the right posterior hepatic duct(RPHD).Then,the common bile duct(CBD)is formed when the cystic duct joins with the CHD(Fig.1).Type A2 refers to the RAHD and RPHD joining with LHD at hepatic hilum,and the absence of the RHD.Type A3 refers to the RAHD or RPHD directly draining to the LHD.Type A4 refers to the RAHD or RPHD directly draining to the CHD.Type A5 refers to the RAHD,RPHD or RHD directly draining to the cystic duct(or aberrant bile duct communicating with the cystic duct,ACC)(Fig.1)[1].
基金The study protocol was reviewed and approved by the Institutional Research Committee,Faculty of Medicine,Chulalongkorn University(No.0482/65)registered in the Thai Clinical Trials Registry(TCTR20211109002).
文摘BACKGROUND Volatile organic compounds(VOCs)are a promising potential biomarker that may be able to identify the presence of cancers.AIM To identify exhaled breath VOCs that distinguish pancreatic ductal adenocar-cinoma(PDAC)from intraductal papillary mucinous neoplasm(IPMN)and healthy volunteers.METHODS We collected exhaled breath from histologically proven PDAC patients,radiological diagnosis IPMN,and healthy volunteers using the ReCIVA®device between 10/2021-11/2022.VOCs were identified by thermal desorption-gas chromatography/field-asymmetric ion mobility spectrometry and compared between groups.RESULTS A total of 156 participants(44%male,mean age 62.6±10.6)were enrolled(54 PDAC,42 IPMN,and 60 controls).Among the nine VOCs identified,two VOCs that showed differences between groups were dimethyl sulfide[0.73 vs 0.74 vs 0.94 arbitrary units(AU),respectively;P=0.008]and acetone dimers(3.95 vs 4.49 vs 5.19 AU,respectively;P<0.001).After adjusting for the imbalance parameters,PDAC showed higher dimethyl sulfide levels than the control and IPMN groups,with adjusted odds ratio(aOR)of 6.98(95%CI:1.15-42.17)and 4.56(1.03-20.20),respectively(P<0.05 both).Acetone dimer levels were also higher in PDAC compared to controls and IPMN(aOR:5.12(1.80-14.57)and aOR:3.35(1.47-7.63),respectively(P<0.05 both).Acetone dimer,but not dimethyl sulfide,performed better than CA19-9 in PDAC diagnosis(AUROC 0.910 vs 0.796).The AUROC of acetone dimer increased to 0.936 when combined with CA19-9,which was better than CA19-9 alone(P<0.05).CONCLUSION Dimethyl sulfide and acetone dimer are VOCs that potentially distinguish PDAC from IPMN and healthy participants.Additional prospective studies are required to validate these findings.
基金This work was funded by the Thailand Research Fund(TRF)and The Office of the Higher Education Commission(OHEC)(MRG6180227 to R.Chaiteerakij)Research Grant:GAT2018 to R.Chaiteerakij,The Gastroenterological Association of Thailandand Research Grant for New Scholar Ratchadaphiseksomphot Endowment Fund Chulalongkorn University(RGN_2559_055_10_30 to R.Chaiteerakij).
文摘Objectives:The difficulties in the early detection consequent to the lack of sensitive biomarkers render patients with cholangiocarcinoma(CCA)to have poor outcomes.Recently,sensitive and specific volatile organic compounds(VOCs)were identified in several cancers.However,the VOC profiles in CCA are not well-studied.Thus,we investigated the VOC profiles in exhaled breath of CCA patients and controls.Methods:We prospectively collected exhaled breath samples from 30 consecutive patients newly diagnosed with CCA and 30 controls who did not have CCA(seven had benign biliary strictures and 23 had other medical conditions).Exhaled VOCs were identified using gas chromatography mass spectrometry Triple Quadrupoles system.Analysis of the significant differences in VOCs between cases and controls was conducted using supervised multivariate regression analysis.Further validation was performed for these VOCs in another cohort of 18 CCA patients and 22 controls.Results:Levels of six compounds were significantly different between CCA patients and controls,namely,acetone,isopropyl alcohol,dimethyl sulfide,1,4-pentadiene,allyl methyl sulfide,and N,N-dimethylacetamide.Acetone and dimethyl sulfide were independently associated with CCA as demonstrated in the multivariate analysis.Using the cut-off value of 8.59107 arbitrary unit(AU),acetone had a sensitivity and specificity of 82.1%and 75.8%,respectively,with an area under the receiving operator curve(AUROC)of 0.85 for the CCA diagnosis.Acetone level was also significantly different between cases and controls in the validation cohort.Using the same cut-off value,the sensitivity,specificity,and AUROC was 59.1%,66.7%,and 0.85,respectively.Conclusion:Breath analysis may potentially be useful for CCA diagnosis.A cohort of patients with earlystage CCA in further studies is needed to confirm the ability of exhaled VOCs for the early detection of CCA.
基金supported by the National Key Research and Development Program of China (2022YFC2407405)the Joint Research Fund Major Project of Gansu Province (23JRRA1488)the Medical Innovation and Development Project of Lanzhou University (lzuyxcx-2022-157).
文摘Fibrosis resulting from pathological repair secondary to recurrent or persistent tissue damage often leads to organ failure and mortality.Biliary fibrosis is a crucial but easily neglected pathological feature in hepatobiliary disorders,which may promote the development and progression of benign and malignant biliary diseases through pathological healing mechanisms secondary to biliary tract injuries.Elucidating the etiology and pathogenesis of biliary fibrosis is beneficial to the prevention and treatment of biliary diseases.In this review,we emphasized the importance of biliary fibrosis in cholangiopathies and summarized the clinical manifestations,epidemiology,and aberrant cellular composition involving the biliary ductules,cholangiocytes,immune system,fibroblasts,and the microbiome.We also focused on pivotal signaling pathways and offered insights into ongoing clinical trials and proposing a strategic approach for managing biliary fibrosis-related cholangiopathies.This review will offer a comprehensive perspective on biliary fibrosis and provide an important reference for future mechanism research and innovative therapy to prevent or reverse fibrosis.
